Population Health Screenings for the Prevention of Chronic Disease Progression

ABSTRACT

Objectives: Early detection of disease enables prompt treatment that can prevent disease progression and costly health outcomes. We report incidence of previously unrecognized disease and investigate the expected effect of early detection and care on health outcomes.

Study Design: Population health study based on laboratory evidence.

Methods: Laboratory evidence of prediabetes, diabetes, chronic kidney disease, and colorectal cancer was evaluated in an employee and spouse population (65% women; mean [SD] age = 46 [12] years). Expected disease progression was assessed.

Results: Annual screening found laboratory evidence for 1185 previously unrecognized cases of prediabetes, 287 cases of diabetes, 73 cases of chronic kidney disease, and 669 positive colorectal screens per 10,000 people.

Conclusions: Early identification and appropriate medical care may delay 34 cases of end-stage kidney disease and prevent diabetes-related complications, 210 cases of diabetes, and 3 cases of late-stage colorectal cancer over 5 years per 1000 cases identified.

Am J Manag Care. 2019;25(11):548-553Takeaway Points

• Early identification and appropriate medical care may delay 34 cases of end-stage kidney disease and prevent diabetes-related complications, 210 cases of diabetes, and 3 cases of late-stage colorectal cancer over 5 years per 1000 cases identified.
• Avenues to detect previously unrecognized and early-stage disease may positively affect the health trajectories of many individuals within 1 to 5 years.
• Employers may serve as a conduit to health screening to benefit the health outcomes of employees and manage healthcare costs.

The majority of employees in the United States have laboratory evidence of chronic disease, and 1 in 3 is likely to have unidentified disease.¹ Chronic diseases, including cardiovascular disease (CVD), diabetes, cancer, and chronic kidney disease (CKD), present a substantial and growing economic burden to large employers in that annual per capita expenditures for persons with chronic disease are 2.3-fold higher (for diabetes)² to 10-fold higher (for advanced CKD)³ than for those without chronic disease. Early detection of and care for chronic diseases enabled by health screening can reduce morbidity and mortality^4,5 and avoid the higher costs of advanced disease.³ For example, all-cause costs of a person with CKD increase dramatically as the disease advances in stage, from $26,843 per year for stage 3 to $76,969 per year for stages 4 and 5 and $121,948 per year for end-stage renal disease (ESRD),³ with $88,000 per year for hemodialysis.⁶

In addition to incurring healthcare costs, employees experiencing poor health may experience absence, short-term disability, and lower productivity.⁷ Without intervention, the chronic disease burden in the US workforce is expected to rise. Fortunately, chronic diseases can be prevented, delayed, or alleviated. The CDC estimates that as much as 80% of heart disease, stroke, and type 2 diabetes cases and 40% of cancer cases could be prevented through modification of lifestyle behaviors. Moreover, most employers (>90%) believe that their healthcare costs could be reduced by improvements in healthy behaviors.⁸ Although most large employers (70%-85%) offer basic health screenings, less than 25% provide a comprehensive worksite population health program that includes comprehensive health screening, access to related health improvement programs, and an environment that supports health.⁹

Employer-sponsored annual health screenings offer an opportunity to facilitate the delivery of population health; the identification of health risk factors offers early opportunities for intervention and connection to care. However, general wellness programs have generated mixed evidence,^10,11 given the broad variation in program designs, organizational settings, and diverse populations in which they are implemented. Evidence-informed programs based on the identification of prediabetes, diabetes, CKD, or colorectal cancer in their early stages may enable more targeted and successful programs that offer early treatment and care that can slow or prevent disease development and debilitating and costly health outcomes. Of all participants in a population health screening with evidence of diabetes, 28% were previously unrecognized, and of all participants with laboratory evidence of CKD, 89% were previously unrecognized.¹ In addition, colorectal cancer screening via stool testing for hemoglobin may increase detection of lesions due to higher acceptance of the test method¹² and a participation rate 40% higher than that of colonoscopy.¹³ However, the longitudinal impact of annual health screenings on disease progression and health outcomes is largely unknown. Thus, the purpose of this analysis was to evaluate the projected value of annual health screenings in 35,258 employees and spouses who participated in annual health screenings in 2017 for early detection of prediabetes, diabetes, evidence of CKD, and hemoglobin in stool on disease outcomes and progression.

METHODS

Laboratory evidence of prediabetes incidence and diabetes incidence was assessed in 35,254 employees and spouses of a single employer who participated in annual health screenings in 2017. Prediabetes was defined as having a glycated hemoglobin (A1C) measurement between 5.7% and 6.4% or a fasting glucose (FG) measurement between 100 mg/dL and 125 mg/dL. Diabetes was defined having an A1C higher than 6.4% or FG higher than 125 mg/dL. Newly identified prediabetes was defined as prediabetes in 2017 without evidence of diabetes or prediabetes in the prior year. Newly identified diabetes was defined as diabetes in 2017 without evidence of diabetes in the prior year. Cases of diabetes prevented by intervention and care were projected based on results of the Diabetes Prevention Program.¹⁴ Expected incidence of CVD and microvascular complications (retinopathy, neuropathy, and nephropathy) were projected based on previous reports.^15,16

Laboratory evidence of new-onset CKD incidence was assessed in employees and spouses who participated in annual health screenings in 2017 (35,258 participants). Evidence of CKD was defined as a single estimated glomerular filtration rate (eGFR) measurement of less than 60 mL/min/1.73 m² without CKD in the prior year. Confirmed evidence of CKD and progression rate to stages 4 and 5 disease and ESRD were projected based on previous research.^17-20

Colorectal cancer screening was offered to eligible employees and spouses aged 50 to 75 years who participated in annual health screenings between 2013 and 2017 (18,976 tests). A positive screening test was determined by the evidence of hemoglobin in the stool from a fecal immunological test (FIT), InSure FIT (Clinical Genomics; Bridgewater, New Jersey). Follow-up colonoscopy results²¹ and stage distribution²² were based on prior research.

RESULTS

Screening for prediabetes (A1C of 5.7%-6.4% or FG of 100-125 mg/dL) identified 1185 (11.9%) cases not recognized in the previous year (previously unrecognized) per 10,000 individuals screened. Based on the Diabetes Prevention Program¹⁴ results, we estimate that for every 1000 confirmed prediabetes cases, 210 diabetes cases can be prevented over 5 years (Table 1^2,14,23,24).